Provider Demographics
NPI:1659707834
Name:KONKLE, MICHAEL YOUNGBLOOD
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:YOUNGBLOOD
Last Name:KONKLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11894 CHARLTON RD
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636-8637
Mailing Address - Country:US
Mailing Address - Phone:559-645-4316
Mailing Address - Fax:
Practice Address - Street 1:2772 SOUTH MARTIN LUTHER KING BLVD
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93706
Practice Address - Country:US
Practice Address - Phone:559-265-4800
Practice Address - Fax:559-265-4823
Is Sole Proprietor?:No
Enumeration Date:2013-09-19
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)